Healthcare Provider Details

I. General information

NPI: 1538879648
Provider Name (Legal Business Name): JUSTUS DENTAL HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 05/18/2025
Certification Date: 05/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 BROUGHTON AVE
ANDREWS SC
29510-5583
US

IV. Provider business mailing address

PO BOX 1010
KINGSTREE SC
29556-1010
US

V. Phone/Fax

Practice location:
  • Phone: 912-996-3303
  • Fax: 866-379-9998
Mailing address:
  • Phone: 912-996-3303
  • Fax: 866-379-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LATHONIA BENNETT
Title or Position: DENTIST
Credential: DDS
Phone: 912-996-3303